Healthcare Provider Details

I. General information

NPI: 1205037264
Provider Name (Legal Business Name): PROVIDENCIA JUSINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB SANTA CRUZ # 70 CALLE SANTA CRUZ
BAYAMON PR
00960
US

IV. Provider business mailing address

CARR 830 KM 4.1 CERRO GORDO
BYAMON PR
00956
US

V. Phone/Fax

Practice location:
  • Phone: 787-740-4747
  • Fax:
Mailing address:
  • Phone: 787-279-5310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2127
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: